Definitions

(1) “Adjusting Entity” means a trade or professional association, managing general agency, pool, third party administrator and/or insurance company licensed to write workers’ compensation insurance in Tennessee and shall also mean a self-insured Employer or group self-insured Employers possessing a valid certificate of authority from the commissioner of commerce and insurance pursuant to T.C.A. § 50-6-405. (2) “Adjuster,” “claims adjuster,” “med-only adjuster,” or “claims handler” or “designee” means a representative of an adjusting entity who investigates workers’ compensation claims for the purposes of making compensability determinations, files or causes claims forms to be filed with the Bureau, commences benefits, authorize and pay timely the correct payment of medical expenses, under the Tennessee Medical Fee Schedule, incurred by the injured worker in accordance with the provisions of Rules and Regs. 0800-02-17, 0800-02-18, and 0800-02-19 and/or makes settlement recommendations based on the insured’s liability on behalf of an adjusting entity and self-insureds. (3) “Administrator” shall have the same definition of “Administrator” as in T.C.A. § 50-6-102. (4) “Assigned by Jurisdiction Number” means a unique number designated by the Bureau upon the request of an adjusting entity, to be used for EDI reporting purposes when the Employee’s Social Security Number is unknown. (5) “Bureau” means the Tennessee Bureau of Workers’ Compensation as defined in T.C.A. § 50- 6-102, an autonomous unit attached to the Department of Labor and Workforce Development for administrative matters only, pursuant to T.C.A. § 4-3-1409. (6) “Claim” means a demand for something as due; an assertion of a right or an alleged right. (7) “Clearing House” shall have the same meaning as in Rules 0800-02-26 Definitions. CLAIMS HANDLING STANDARDS CHAPTER 0800-02-14 (8) “Electronic Data Interchange” or “EDI” means the electronic communication method that provides standards for exchanging data via electronic means. The term “EDI” encompasses the entire electronic data interchange process, including the transmission, message flow, document format, and software used to interpret the documents using the standards established by the IAIABC and the Release Version accepted by the Bureau at the time of the filing. (9) “Electronic Form Equivalent” means the original document, provided on the Bureau’s website, which is to be used when a sender reports required data via a paper document. When forms are reproduced, they shall be reproduced in their entirety, including instructions and shall not be modified without written consent of the Administrator. A form may be revised at any time at the discretion of the Administrator and will be available at no cost. (10) “Employee” shall have the same definition of “Employee” as in T.C.A. § 50-6-102. (11) “Employee Security ID” means a unique number assigned by the Bureau upon the accepted filing of an initiating FROI to be used rather than a Social Security Number for SROI filings to protect the privacy and security of the Employee. (12) “Employer” shall have the same definition of “Employer” as in T.C.A. § 50-6-102. (13) “First Report of Work Injury” or “FROI” means the initial report designed to notify the Bureau of the claim of an injury or illness. (14) “Form” means the document as is available on the Bureau’s website on the date of the filing. (15) “Hospital” means the same as in Rules 0800-02-19 Definitions. (16) “IAIABC” means the International Association of Industrial Accident Boards and Commissions. (17) “Injury” and “personal injury” shall have the same definition of “injury” as in T.C.A. § 50-6-102. (18) “Insured” shall have the same definition of “Employer” as in T.C.A. § 50-6-102. (19) “Medical-Only” claim or “med-only” claim means a claim requiring medical attention, but which has no indemnity benefits due or paid. Any claim in which no indemnity benefits are due or paid, but which has medical treatment provided by any medical personnel qualifies the claim for medical only status, regardless of whether or not a bill is generated and regardless of whom pays for the medical care. (20) “Medical Provider” means an individual or entity involved in delivering healthcare services to Tennessee workers’ compensation injured Employees, that play a role in diagnosing, treating, and managing the health and well-being of injured workers and includes physicians, surgeons, nurses, physician assistants (PAs) nurse practitioners (NPs) dentists, pharmacists, therapists, mental health professionals, hospitals and clinics, diagnostic service providers, and allied health professionals including but not limited to medical technologists, radiologic technologists, and others who support medical care to injured Employees. (21) “Subsequent Report of Injury” or “SROI” refers to the group of transactions of workers’ compensation claim processing filed, via EDI, when required after an accepted FROI that typically report the benefit, payment, return to work, and closure data. (22) “Trading Partner” means an entity approved by the Bureau to exchange data electronically with the Bureau on behalf of an adjusting entity. CLAIMS HANDLING STANDARDS CHAPTER 0800-02-14